Failure to Provide Timely Laboratory Services Due to Unlabeled Urine Sample and Lack of Follow-Up
Penalty
Summary
The facility failed to provide timely laboratory services as ordered by a physician for one resident, resulting in a delay in diagnosis and treatment of a urinary tract infection (UTI). The resident, who had a history of diabetes, COPD, and benign prostatic hyperplasia, began experiencing symptoms of a UTI, including dysuria, cloudy urine, and urinary frequency. A urinalysis with culture and sensitivity was ordered, and a urine sample was collected and sent to the laboratory. However, the sample was not labeled with the resident's identifying information, and the laboratory did not process the test as a result. Despite the resident's ongoing symptoms and repeated requests for pain medication, there was no documentation that the facility followed up with the laboratory or the physician regarding the missing urinalysis results for several days. The resident continued to experience pain and discomfort, and a second urine sample was not collected until four days after the initial sample was sent. The facility's records did not indicate the reason for the delay or the need for a second urinalysis, nor was there documentation of any attempts to recollect the sample prior to the second collection. Interviews with staff revealed confusion and lack of awareness regarding the resident's urinary issues and the status of the laboratory tests. The DON, ADON, and other staff members were unable to provide clear explanations for the delay or confirm whether the laboratory had been contacted after the initial sample was found to be unlabeled. The facility's failure to ensure proper labeling, timely follow-up, and clear documentation resulted in a significant delay in providing necessary laboratory services to meet the resident's needs.